 Hi, everybody. We'll be starting in a minute or two. Thank you for joining us today. Good afternoon, everybody. I'm delighted that you're joining us for today's important talk on ethics in the COVID-19 pandemic, medical, social, and political issues. As you know, in the winter quarter, we will be concentrating on the issue of disparities quite often. Let me introduce Dr. Albert Wang, I'm sorry, Dr. Albert Wang, who's Professor of Medicine and Public Health Sciences and also serves as the Director of the Center for Chronic Disease Research and Policy here at the University of Chicago. From 2010 to 2011, this was during Barack Obama's presidency and during the development of the Affordable Care Act. Albert served as a senior advisor in the Office of the Assistant Secretary of Planning and Evaluation in the Department of Health and Human Services. Albert is a practicing primary care doctor who studies clinical and health care policy issues at the intersection of diabetes, aging, and health economics. Albert's research has provided the theoretical and evidence-based foundation for the concept of personalizing diabetes care goals, as well as the contemporary natural history of the disease, diabetes in older people. Dr. Wang's research has directly influenced modern diabetes care and clinical practice guidelines for older people in some of the following ways. One, by the individualization of glycemic goals. Two, by the role of patient treatment preferences. Three, the clinical importance of hypoglycemia. And four, the management of geriatric conditions. Albert is an expert in the use of computer simulation models of chronic diseases. As a primary care doctor here on the south side of Chicago, Dr. Wang routinely sees how gaps in our patchwork of safety net policies lead to crucial deficiencies in care over a lifetime from young adulthood to middle age to old age. Albert's central policy interest is to strengthen the primary care safety net in order to improve the health of vulnerable populations. Specific areas of policy expertise include the following. One, diabetes and obesity epidemic. Two, the aging population and long-term care. Three, the rising cost of prescription drugs like insulin. Four, the value of federally qualified health centers. And five, primary care and geriatric workforce. Today, Albert will work on a panel with Stacy Levine and Tamara Kineska as they address the topic of disparities in nursing homes. I now will turn the meeting over to Albert who will introduce Stacy and Tamara and will also be looking at your introduction of questions through the chat network here on the screen. So let me turn the meeting over to Albert Wang. Albert, please. Great. Thank you, Mark, for that kind introduction. I will start with a brief, just a brief discussion to set up our conversation. We're very lucky to have really two national experts on long-term care at University of Chicago. And I think this has been one of the most important areas of healthcare over the last year. And I'm looking forward to hearing their experiences and thoughts about the future. So I just wanted to briefly set up, you know, how we arrive at disparities in long-term care and talk briefly about some long-term trends behind COVID-19 disparities that may be, some of you may already know about, but I want to bring together to set up this conversation with our two experts. One is that one trend, of course, is that the United States, like other developed nations, like those in Europe or in Japan, have shifting demographics such that we are going to have already in the near future, will have an increasingly older population. And this is a demographic, what they call the pyramid shape, where in a population that's made up mostly younger people, like we did in 1960, the base is bigger, made up of younger people and shrinks to the top as the number of older people is, let's prominent. But as this graphic shows, the projection by 2060 is that our pyramid demographic will shift to more of a pillar by 2060 where the representation among older patients, older people within our population will be higher in terms of sheer numbers, in terms of millions of people. In addition to our country becoming older, we are also becoming a more diverse country. This is another graphic coming from the Census Bureau, which shows the shift in the racial and ethnic composition of different age groups going from 2010 to 2018. And you can see that even here over in the, for those over 65, older people are also becoming a more diverse population in the United States. And you can sort of see that by the increasing number of colors of people of different racial ethnic backgrounds other than white. And so this graphic shows not only that those over 65, that population is going to increase, has increased over time, but has become also more diverse over time. And there are certain things that come with a population becoming older. And one of them is unfortunately chronic diseases of older age, which includes Alzheimer's disease. Certainly this graphic also looks similar for chronic conditions such as diabetes, hypertension, cardiovascular disease. I feature Alzheimer's disease because it happens to be a condition that results in a person's dependency on others, right, as one loses the ability to perform independent activities of daily living. And the need for assistance in activities of daily living have a direct connection to the need for services that are provided in long-term care. So the long-term care population, I tried to find the latest information about the racial ethnic composition of the US nursing home population. And I think there is some more recent publications, but this trend analysis from Vincent Moore between 1999 and 2008 still is pretty informative and I think still holds up. This shows, this is an analysis of data from the minimum dataset of all people living in nursing homes. And you can see that in 1999, 86.7% of the nursing home population was white. And the nursing home population has become more diverse. By 2008, the proportion that were white had declined while the proportions of residents that were black, Hispanic, and Asian had all increased. And you can sort of see, you can see over here that the proportional increase is quite dramatic for Hispanics and Asians. And you can sort of see that this mirrors actually the general racial and ethnic diversification of the US population below is, those overall trends in the general population are probably the principle drivers of the change that happen in long-term care. So when we talk, when Stacy and Tamara talk about racial and ethnic disparities, keep in mind that this is happening in the background of shifting demographics and a increasingly diverse long-term care population. So why, just I want to set up a couple, mention a couple of things that we've observed from a study that I'm part of called the National Social Life Health and Aging Project. We know that the COVID-19 pandemic has caused great morbidity and unfortunately death among our older patients, especially in long-term care settings. But I want to just make a comment about, you know, the future, which is going to be what, you know, among those of us who have survived this pandemic and those who survived the pandemic in long-term care settings, many of them were subjected to important public health measures such as social distancing. And this is just an analysis of a community dwelling sample of people from NSHAP where we surveyed people's mental health in 2015 and 16. And in this last year, we did a special survey of those during the pandemic. And we asked them basic things about their happiness, their relationships, whether or not they felt isolated or not as a result of the social distancing that was required during the pandemic. And what stood out for me in this survey is that the proportion of people that were older people, actually, there is depression and unhappiness, but in 2015 and 16, this sample, 58% of them were very or extremely happy. And you can sort of see in the shift from the blue to the purple, this big shift in the mood of the cohort from 2015 to 2020, the proportion that were very or extremely happy dropped from 58% to 28%. The level of, you know, related to this, people were shifting and becoming more depressed with the proportion depressed rising from 27% to 43%. So this just shows them at a population level, big shifts in the mood of an entire generation. And why does that matter? Why does the feeling of depression or isolation matter? This is data from the same study. This is a paper led by Meltem Zatenoglu from Endocrinology, who looked at people's self-report of loneliness and their future risk of falling out. And in this analysis, she finds that with each increased step in the loneliness score, that a person's predicted probability of fall increased in the kind of linear fashion. So the things that we talk about today in terms of the crisis, the fire of the COVID-19 pandemic, I'm not going to go into too much detail about the COVID-19 pandemic. I'm predicting that we are going to be for several years studying the consequences of not only the tragedy of the infection itself, but the consequences of our public health measures going forward. So with that background, I'd like to introduce our two speakers today. First is Dr. Stacey Levine, chief of the section of geriatrics in the Department of Medicine. Dr. Levine is a board certified geriatrician, not only in geriatrics, but also in hospice and palliative care services. She's currently co-PI of a large scale multi-center project in primary palliative care education that involves longitudinal training and clinical and teaching skills, program development, leadership engagement, and patient advocacy for physicians and other providers. She's also a co-investigator on the HRSA-funded geriatric workforce enhancement program at your Chicago called SHARE, supporting healthy aging resources and education, which develops community-based primary care clinicians in geriatric medicine and creates a supportive collaborative network of older adults in the community and nursing home settings. Dr. Levine serves as medical director in geriatrics and has cared for patients in long-term care and skilled nursing home settings for nearly 20 years. She has presented and published on her experience in Caringford COVID-19 patients in these settings and currently serves as lead faculty on an ARC-funded project with Echo Chicago to train over 200 nursing homes in managing COVID-19. Our second speaker is Artamara Kanetzka, who is the Lewis Block Professor of Public Health Sciences with a secondary appointment in the Department of Medicine in the section of geriatrics. Dr. Kanetzka is an internationally recognized expert in health economics of long-term and post-acute care. Her research focuses on incentives created by healthcare policy, including payment policy and their effects on quality of care. She's been a PI on numerous major federal research grants leading to significant advances in the knowledge of drivers of nursing home quality, how public reporting of quality changes the behavior of providers and consumers, and the unintended consequences of home-based long-term and post-acute care. She is the editor-in-chief of medical care research and review. So if you followed the news at all, Dr. Kanetzka's expertise has been featured on the national stage in addressing the devastating effects of COVID-19 in nursing homes. She was among the first to produce rigorous evidence predicting that nursing homes would face the highest probability of COVID-19 outbreaks and deaths. In May, she testified before the U.S. Senate Special Committee on Aging in a hearing on COVID-19 and older adults serving as the sole nursing home expert. And she's been sought after by policymakers of every level from the federal, state, and local government agencies and is widely sought after by reporters from the New York Times, Washington Post, Wall Street Journal, the Atlantic National Public Radio, and ProPublica. She is working, she could use the word callously to minimize the devastation and move towards a high quality equitable system of long-term care financing and delivery. So with that introduction, I'd like to pass this on to Dr. Levine. Dr. Levine? Okay, just give me a second to get my slides up. Thank you so much for that warm introduction. Hello, everybody. Thank you for being here today on this very important day. So I'm going to take you through a case. And it's going to be my lived experience as a medical director in a skilled nursing facility on the south side of Chicago. And I'm titling my talk, A Tale of Two Pandemics, because we know that this virus disproportionately affects communities of color. We've learned about that in the news. And the large number of cases we've seen are disproportionately in our older adults, particularly in the nursing home population. And the numbers that we see typically are that less than 4% of older adults in our country live in a nursing home or an assisted living facility, yet 40% of deaths are attributed to these, this patient population. So with that, I'm going to go over the case of our experience with an early outbreak of COVID-19 in a Chicago Southside nursing home that we work at and we'll cover some of the ethical and clinical response issues that we had to address with this outbreak. So here's my building. This is Symphony South Shore. It is located right next door to our senior clinic. And for those of you that know geography around Chicago, it's across from the lake. It's about eight minutes away from our University of Chicago campus. It's a four story building. At most it has about 230 residents in the building. It's a mix of both short term rehab and long term care. And we do have a locked dementia unit on the third floor. And it's staffed primarily by Symphony hired nurses, CNAs, LPNs, therapists, and all sorts of other people. And then the University of Chicago team, we manage about half of the building of our patients. And then there's other physicians groups that come in and out of the building. It's predominantly a Medicaid building with some Medicare. So definitely I would say one of our safety net nursing homes in Chicago Southside, and it does represent our community. So we take all commerce to this building. We, we have people that have chronic morbidities, psych disorders, substance use disorder. We have patients who have been homeless that have contracted COVID-19 and can't go back to their shelter. So we take them onto our COVID unit. So it really is a very rich and very at risk population that we're taking care of in this building. And what I want to point you to here is this white box on the back of our clinic door. This is a lab box. And this became a very important part of our care team when we were going through this outbreak. So there's been a lot of op-eds and editorials written about the nursing home crisis in this country. This one I pulled out for you. And I want to quote some of this from this particular person that published this last year. And they said the failure to plan adequately in this sector while acute and critical settings received most of the pandemic planning attention is a reflection of the longstanding low visibility of these care environments. And they said that this is an actual humanitarian crisis. They went on to say that when human value is mainly tied to economic contribution, old and disabled bodies are perceived to have outlived their usefulness and are thus are undervalued. Fragility and dependency are negatively perceived as a burden. Thus provision of care in this group of individuals is not considered a priority. And they are often left in insecure and vulnerable positions. So let's begin with our story. If you recall back in February was when we were learning more about this virus hitting our country and the very first nursing home we heard about having an outbreak was life care center in Kirkland, Washington. We're watching in shock and horror. All these cases coming through. And then shortly thereafter we were hearing about the East Coast getting hit very hard with all these COVID-19 cases in their nursing facilities. And so here in Chicago in the middle of the country, we knew it was a matter of time before the virus would make its way into our buildings. So we were starting to plan. The CDC and the Department of Public Health were still very early in discovering and knowing about this virus, how it impacts our elderly population. So around the middle of March, the CDC ordered that we would close to all visitors and restrict consultants and others coming into the building. And we also had to lock down our gym in our common room. So you can see here on the right, our gym has been completely empty now for many months. And the common room where people typically eat dinner together is empty. There's nobody there. And so then around the 23rd of March, we admitted a patient from an outside hospital who acutely decompensated within 24 hours and had to go back to the hospital. And we did not know that this was a COVID-19 case until about a week later. So the next day, the roommate of this patient spiked a fever. And the protocol at that point in time was to test them for influenza first. And we did not have access, readily access to COVID-19 testing. So we had to send the testing out. And we found out very quickly that this person did have COVID-19, this roommate. So within 24 hours, we had to create a COVID unit. We had to move a whole bunch of patients off of half of the floor, immediately stop new admissions. Because we knew that with one case, you consider yourself to be an outbreak. So you can just imagine the chaos that this created. So I'm going to go through some challenges throughout my talk about the early pandemic. Again, we're talking about the early pandemic. We know a lot more about the virus now than we ever have before. But back then we didn't know very much. We were going to talk about the scarcity of resources, limited guidance that we had at the time, what we did about end of life decision making and advanced care planning and social isolation. All right. So let's talk about scarcity of resources. You've heard all about this. It's been all over the news about the scarcity of PPE. And it certainly disproportionately impacted the nursing facilities. You know, most of the PPE was being deployed to hospitals who were also suffering from shortages. And so, you know, during this time we were spending our time procuring, you know, PPE from the community. We were getting N95 surgical masks, donated homemade face shields. We were using disposable rain jackets for our gowns. I mean, we really had very, very limited supply. And it wasn't for lack of trying. Certainly wasn't for lack of trying. We had a lot of staffing and huge staffing concerns. So nursing facilities in general, before the pandemic have issues with staffing. We have a lot of staff turnover. And then you add on to this, the pandemic and this tremendous fear, understandable fear of catching the virus, especially when people were not adequately protected with PPE. So we struggled the first week with staffing. And at the same time, the Chicago public school system had closed down. And these young staff members had to go home and take care of their kids, where they live in multi-generational homes and they're worried about giving the virus to their parents or they may have asthma or other illnesses of their own that they're worried about. And so we struggled with some staffing. The leadership did offer hazard pay to our staff to get them to come into work. So that was one really important thing that helped us. And, you know, testing was very difficult. We had a testing turnaround time of about seven to 10 days, which obviously is not going to help the situation. We're not going to know who has the virus in time to really be able to make a dent in preventing spread within the building. And I, at one point I'd call the Chicago department of public health and say, you know, we need some help here. We were in outbreak and we just don't know what to do. And they said, you know, we really feel for you. We're in the same boat. We have very limited testing capacity. What I would suggest you do now is if you have one case in the building, that you would be able to test the virus with that, so you wouldn't have to have the virus in your own body, with symptoms who tests negative for influenza has the disease. So that was the advice we had back then. So. What did we do? Well, we put in universal masking. There wasn't universal masking mandate at the, at the time we had everybody in the building start wearing a mask where we could find masks. Including cloth masks. Anything that we could find. during outbreak. So, I am very fortunate to have several physicians in my group, including, you know, faculty members, as well as I had three fellows at the time who we could increase our presence on the floors in the nursing home. It was very important that the nurses and other staff saw the doctors that were there every day. You know, people had asked me, well, what about telehealth? Could you guys do telehealth? And you know, we really tried to do some of that, but it's very difficult when the nurses are running around trying to take care of patients to expect them to go on an iPad and talk to a doctor in another room or in another building. So, we just made a pact with ourselves that we were going to go in and we're going to be able to support everybody and provide seven-day week coverage for these patients. We also asked the other physicians groups that were coming into the building if we could take care of their patients. We had about 80 patients that we absorbed because we wanted to reduce the number of additional staff coming in and out of the building. And then at that time, we relied on symptom-based testing. And the way we did this was we worked with the University of Chicago through our clinic next door who were able to provide us swabs. And we would drop them in that little white box I showed you and get the results back within 24 hours, which was much better than a seven to 10 day turnout for a turnabout for a PCR test. However, even despite doing this, we still had, you know, every day we'd have three to four new fevers or new symptoms and, you know, over about 10 days, we got to a point where we had it over 40 known or suspected infections. So, this obviously wasn't very good. We knew we weren't going in the right direction. So, I emailed our hospital incident command team and said, you know, I'm glad the hospital's doing great. They had things under control as best they could, but if we could fix one problem today in the nursing facility, it's the need to test the entire building. We are now at a point where we need to cohort our COVID-negative patients and we cannot find them unless we test them. So, that was an email that went out and I got an immediate response from our Hicks team who said, how can we help you? Let's get an infectious disease involved. Let's see how we can get this building out of outbreak. So, again, you know, I mentioned that there was limited guidance back then. The CDC was trying to figure out how to advise nursing facilities. We didn't have a testing strategy. We didn't have a cohorting strategy. So, we really had to go about it ourselves and honestly, like I, there was a California nursing facility that had done this point prevalence testing where they tested the entire building and I said, you know, I think we need to do this and infectious disease agreed. So, what this is is you literally have to take all the cases in the building that you don't know their COVID status yet. You come in and you test them all in one day, which is a huge effort. I mean, you need several people to come in to test everybody. You need testing kits. So, thankfully, University of Chicago jumped in on a Sunday morning. We had like at least 10 teams of people coming in who helped us test the entire building and we knew we were going to have a lot of asymptomatic positives at this point in time. So, we did 120 tests. 77 of them came out positive and we ended up with 43 negative cases. Of those 77 positive, about 60% of them were what we considered asymptomatic or pre-symptomatic. So, a really huge number of people who were, you know, in their rooms trying to stay away from people or possibly going outside and smoking or, you know, we had some dementia patients on the dementia unit were wandering around who possibly had COVID-19 and we did not know it and they were spreading it around to other people. So, once we identified who was negative, we moved them to their own floor and put each of them in their own room in isolation or quarantine with proper PPE so that the staff could protect them. And then we had to notify all the family members of people that we did this testing. We didn't notify them before the testing and after the testing and one of my fellows did a fantastic job recruiting people to volunteer to call family members. He actually published it last year. And then, you know, a week later we did another point prevalence testing on the COVID negatives to see if they were still negative or if they turned positive and you can see here that about 12 came back positive in that week and the majority of them were actually on our dementia unit which was probably the most difficult place to quarantine or isolate people. And one of our infectious disease fellows, Maggie Collison published this as well, this experience. So, that's how we addressed our outbreak. And at the end of the day on the 24th of April, just to give you a sense of numbers in the building, we had 119 COVID positive cases in our building. If you compare that to University of Chicago Hospital, we had 129 confirmed COVID positive cases. So, while the ones in the hospital were sicker, I would argue that we were running a mini hospital at that point in time in the nursing home. Another very important consideration that came up was messaging in the media. So, you have all seen how the nursing homes were doing in the in the media. It was quite tragic and very demoralizing to see all the nursing homes be portrayed as, you know, you know, suffering insufficient. You know, it was hard for our nursing staff to see that every day. And when I called the leadership from Symphony and asked them about this point prevalence testing, you know, their first reaction was, oh my gosh, we're going to have all these positive cases. How are we going to respond to that? And, you know, they agreed that we should do it. It was the right thing to do clinically, but they also wanted to know how we're going to actually discuss this in the media. And so, what we decided is they were going to contract with a PR firm. And we were going to drive the messaging. We were going to be proactive and say and be very honest about why we did this and why it was important to do this. And, you know, that night when the news broke, it was all over every news channel. And we had put some messaging out in the newspapers. And then we also had a follow-up article that we did in late last year, which, you know, showed sort of like how we've recovered from all of this. And it was really a nice piece that discussed how the nurses did, how everyone supported one another and how everybody worked really, really hard. And I thought it was just so important. I don't think we hear enough of that in the current media. Definitely not earlier when these crises were happening. Another important ethical issue that came up was the use of off-label therapies. So, as you guys remember, there's a lot of chatter about hydroxychloroquine, maybe a little bit about chloroquine in the news back in the early, like end of February, March. And you can see here the number of prescriptions went way, way up with these drugs because of the stuff that was being portrayed in the media and politically. You know, this was offered to us, actually, that one of the pharmacy, the leads of pharmacies, that we know we have this hydroxychloroquine. It's being used off-label in buildings. Do you guys want to use it? And, you know, we had a lot of back and forth with our, you know, the physicians in the group. And we decided ultimately we weren't going to just go ahead and put people on hydroxychloroquine because it hadn't been studied. I actually had a couple of discussions with some of our patients' family members, and they also were very suspicious. This is a medication you're going to give my dad, and it's not been, you know, properly vetted. So, we decided not to go that route. But I do have a lot of colleagues all over the country who did prescribe some hydroxychloroquine because I think people really felt desperate. You know, we really didn't know what else to do. We didn't have anything to give to people. And we were so scared about our residents dying on us that we felt like we needed to do something. So, I completely understand both arguments, but our group decided not to do it. Now, a little bit of follow-up on this is some of the nursing facilities are being investigated because they had prescribed these medications without properly consulting or receiving permission from the residents or the family members. So, just another thing out there that was sort of a struggle for us cognitively about what we were just going to do to try to help support our patients. And I was a little torn about this, but in the end, I think we made the right decision. Another very important ethical consideration we had to struggle with was regarding end-of-life care, palliative medicine, advanced care planning. You know, we shut everything down. We restricted our visitors. It made it very difficult for having family meetings that were effective. We had to do a lot of advanced care planning on the fly. You know, somebody becomes acutely ill. You need to call their family member perhaps and talk about code status when the family member is not there to see their loved one, hadn't seen them in several weeks. Pulse completion was challenging as well because in Illinois, we require signature and so if people don't have access to, you know, an electronic way to do it, we ended up in many cases doing a two-witness verbal consent just so we had something documented in the chart when somebody was imminently going to pass away. CPR also had some concerns, especially when we didn't have PPE because it's an aerosolizing generating procedure and you need to have full PPE on for anything that requires that. And so we actually formed an ethics committee to talk about like, how are we going to manage these codes if people want CPR? And at the end, the decision that came out, and this was more of a national decision with some of our organizations, was if you don't have full PPE to wear, you don't have N95s, your staff aren't fully protected, then you cover their face with a cloth and you perform chest compressions until the paramedics can get there and take over. But that was, again, a very challenging decision we had to make. And then another really important piece was communication across transitions. You know, historically, nursing facilities and hospitals don't communicate well with one another, especially in the middle of a crisis. And these hospitals are very, very busy and overwhelmed with COVID cases. They need to have the most information they can. So what we decided to do was, anybody that was going to University of Chicago was to drop a note in the chart and the electronic medical record, letting them know the critical information, including who the certificate decision maker is, what their code status discussions were like, and medications and so on and so forth, just so that they had more information to prepare. Albert has mentioned social isolation and loneliness. And this is another big concern, especially as we go on and on with reduced contact. We did over the summer have a point in time where we were able to do outdoor visits with loved ones. And then everything shut down with the winter. And we found it more difficult. But it's very concerning. And I think to his point about the long-term consequences, we don't know yet what this is going to look like. There's social isolation, which is the objective, really distancing somebody from another human being. And then there's loneliness, which is actually the subjective feeling of being by yourself. And we know pre-COVID that 40% of residents in skilled nursing facilities report having severe loneliness, which is twice the rate of community dwelling elders. And this can lead to increased reporting of symptom burden near the end of life and increased requests for high-level end of life care, such as being in the ICU or going to the hospital. So we've struggled with this. In the middle picture, you'll see that's an empty dining room that we now use for some social distancing activities. We're trying to bring some residents out of the rooms and put them there. So they have some interaction. You see other nursing homes have done things like this hugging wall with the plastic. And then you have people that you see on TV, they're looking at their loved one from outside the rooms. We use a lot of iPads for visits, but this is something that's been very tragic for our family members in particular, especially the ones with dementia, because the dementia residents don't fully understand at all what's going on. And they really relied on their loved ones to come in and feed them and hug them. And now they're not there, now they're gone. Okay, but I do want to end on a positive note here. I just have a few more slides. And that is that things are improved for sure. Over the summer, we had gotten some money from the federal government and we had gotten some these point of care antigen testing kits so that we can test people that are symptomatic and get results back within 15 minutes. And that's been very helpful for us. We're now testing the staff based on the county prevalence of the illness. So I get tested once or twice a week, depending on the county prevalence as to the other staff, which we hadn't been testing staff prior to all of this. We have a COVID unit, you'll see the zip up door there. And we have, you know, plenty of PPE right now, which is great. Our staff are feeling much more comfortable. We're cohorting residents properly based on guidance from the CDC. So things are definitely turning into a positive direction. However, there are still many facilities that are an outbreak right now. And this is data from last week, you can see in Chicago alone, there's 73 nursing homes that are reporting active outbreaks. So this problem is not gone. You know, it's still going to be with us until we get the vaccines and get them in people's arms. So last week, my building had CVS come over and provide vaccines to our residents and staff members that were consenting to the vaccine. And we had over 100 residents who were vaccinated and about 30% of the staff so far have been vaccinated and we're continuing to help educate and, you know, help, you know, have conversations about concerns about vaccine hesitancy. We know that this is a big issue not just in nursing facilities, but elsewhere with healthcare workers. So we're really listening and understanding where they're coming from and waiting to see if they become more comfortable, but we're certainly not allowed to pressure people or force them to get the vaccines. And then I also want to mention that, you know, we took this really tragic experience. I mean, in all, all told, 83% of our building was infected with COVID. We have one of the highest infected buildings in the state of Illinois. It's not something that I feel particularly proud of. But what I am extremely proud of is the way we handled it. Very lucky to have University of Chicago backing. I have a fabulous faculty and fellows and we have a great staff. Our fellows, for example, in May worked with Echo Chicago to create six sessions that we deployed across the state of Illinois for nursing facilities to help educate them on things like wearing PPE properly and how do you handle infection control. And now we're partnering on this big ARC project with Project Echo. This is national. They're trying to train 15,000 nursing homes and we're working with Project Hope, which Project Hope is a long-standing non-for-profit organization that does humanitarian work, including crises like infectious crises. You know, they were very active in the AIDS crisis and we're working with them in education using Project Echo on over 200 nursing facilities. It's been a very rewarding experience for me and a way for us to give back what we've experienced. I'm going to end with just, again, thanking this was certainly not all me, a huge team of people. Dr. Lauren Gleason, who is my co-medical director of Symphony South Shore, all of my doctors are fantastic APPs that helped us out and we're there literally every day on the line. Our nursing staff, administrators, all the CNAs, LPNs, environmental services, food people, everybody really joined together to help support our residents. I feel very proud of how things went and that's why I'm very happy to continue to work there. So thank you and I look forward to your questions at the end of all their sessions. Thank you Dr. Levine and we'll move quickly to Professor Canetska. Great. And if you have questions, please type them in the chat or the question and answer box. Just bring this up, okay. And you can see the slides now. Great. Thank you, Albert and Stacy. Every time I hear Stacy tell the story of what happened at South Shore, I'm struck by three things. First, how prescient she and her team were in how they handled this crisis because indeed, I think what she implemented soon became best practices across the nation. Second, how much her experience at a local level is completely in sync with what I've observed at a federal level and in the national data. And third, I'm always struck by how it was very helpful that she and her team were able to leverage the resources of the University of Chicago when testing wasn't widely available and they really needed to test in order to implement what became best practices. So that always makes me wonder, what about all of those nursing homes that didn't have those resources of a major hospital to lean on, which feeds into our disparity discussion. So I'm going to set up what we know about nursing homes and the pandemic more generally on a national level before getting into some of the disparities issues. The effects of the pandemic in nursing homes have often been referred to as a kind of perfect storm involving three major factors. One is attributes of the virus itself that we weren't really prepared for. Two is the setting, the nursing home setting, and three is the policy context. So in terms of attributes of the coronavirus, as we all know now, it's an airborne virus that can be asymptomatically spread. And we didn't obviously really know that in the beginning or at least that wasn't widely known. And so a lot of the procedures we had in place in nursing homes really focused on cleaning and hand washing and those things that perhaps are not as critical as some of the measures used to prevent airborne spread. So one is we had a virus that we were dealing with that we weren't quite prepared for. In terms of the setting, obviously nursing homes are congregate settings. There are lots of older adults there with underlying health conditions. That's in fact why they're there. And they need hours of hands-on care every day. Many nursing homes across the country have multiple residents per room. And then of course, somebody needs to actually give the hands-on care. And so staff spend hours of care, hours every day on caring for residents, and they themselves go in and out of the facility every day. So it's not the kind of situation where we can socially isolate people to prevent them from getting the virus. And as Stacy mentioned, there is chronic understaffing in many facilities. And one needs staffing to address an infectious disease outbreak in a nursing home. And finally, there's the policy context. And this is an area where I spend a lot of my time working and thinking. So first of all, as again, everybody knows, there was a failure, I would say, a failure on the federal level of policymakers to secure the supply chains for testing and PPE. And that was a general problem in the pandemic. But nursing homes really felt the brunt of this because they weren't prioritized early in the pandemic. And Stacy referred to this as well. So if we think back to spring when the heroes, the healthcare workers were being celebrated, long-term care workers were often not part of that celebration. And then in terms of actual material distribution of PPE, we saw states fighting with each other to try to procure enough PPE for the healthcare facilities in their states. And during that whole process, states were also mostly prioritizing hospitals. So in many ways, nursing homes were just sort of at the end of the line forgetting those materials, including both testing and PPE. And in the meantime, there were nursing home workers who were working for months, sometimes for hours every day on COVID positive patients without being appropriately protected. Some of this comes from a general reluctance by policymakers to assist a largely for-profit industry. I think in general as a society and certainly among policymakers, there's a real ambivalence to giving this kind of assistance to the nursing home sector that we don't see in other sectors. So in hospitals, for example, about three quarters of hospitals, last time I looked, were non-profit and about a quarter or for-profit. In nursing homes, it's the opposite. About three quarters are for-profit facilities, and many of them are chains. And so people who worry about nursing home quality often attribute quality problems to this profit-seeking behavior. And then when there's a crisis, I think there's just ambivalence toward assisting a sector and assisting providers that people just generally don't trust in terms of their underlying motives. And I think the reality is much more complicated when you look at the data. There's not such a strong causal connection between for-profit status and the quality of care. It's much more complicated in reality, but that doesn't eliminate the fact that there is this ambivalence. So how do policymakers deal with this ambivalence? There was some aid given out. The CARES Act back in May did include money for nursing homes, but at the same time, there was a strong focus on imposing more guidelines, conducting inspections, infection control inspections in nursing homes, and finding those that weren't doing well. And this, to me, in the middle of a crisis was misguided, and I'll return to that a little bit later. So in the end, nursing homes basically didn't have the resources they really need. So the result of this perfect storm, the confluence of these factors, was that we've seen 136,000 or so COVID deaths in long-term care as of December, more now. And that includes some staff deaths as well, but obviously, death rates are higher among the nursing home residents. The latest numbers are that this is about 36% of all the COVID deaths in the nation. One statistic that I think is very important is that now virtually 100% of nursing homes in the country have had at least one case. This is clearly not a bad apples problem. They've not all had deaths, but they've all had at least one case and had to deal with this outbreak. So it's not like some have found the magic bullet in terms of keeping cases out. And just to show, there's a lot of variation from state to state. So there are some states where the percent of COVID deaths attributable to long-term care are actually much higher than that average 36%. And what we see is that despite policy measures being implemented over the course of spring and summer and despite these best practices being developed, we still saw a huge fall surge that continues now in both staff and resident cases and in resident deaths. We have by far not solved the problem. Okay, turning to the evidence base, what do we know about which nursing homes have had outbreaks and deaths? And are there attributes of nursing homes that we can point to that show what went wrong or which facilities we should sort of direct our attention to? There's been a lot of research on this. I have done some of this with my awesome collaborator, Rebecca Gorgias, who is now a postdoc here in the Department of Public Health Sciences. So some of these are ours, but there are now almost 20 actually analyses on COVID-19 and long-term care facilities looking at the predictors of these outbreaks and deaths. And there are a couple of different data sources. There's now national data that people have been using, although some of it's pulled from state websites as well. So I won't go into the details of them and just focus on what we've learned from this literature. Perhaps the most important fact that I've been repeating since May is that the strongest predictor of nursing home COVID-19 cases and deaths is the prevalence of the virus in the surrounding community. And this goes back to the idea that staff go in and out every day. So really, the idea that some people have proposed that we can kind of let the virus rage in the community while protecting the most vulnerable people, those in nursing homes, you know, that's just delusional because pretty much no matter what nursing homes have been able to do on their own, they're always at risk. If they're in an area, that's a hot spot. So consistent with that, none of this research has found a meaningful relationship between COVID-19 cases and deaths and any sort of measures of nursing home quality. So many people are aware of these nursing home compare star ratings that are published by the federal government on Medicare.gov. Those basically have no relationship to which nursing homes had outbreaks. Even prior infection control citations in Medicare and Medicaid inspections have no predictive power in terms of which nursing homes had outbreaks. But there are a couple of nursing home attributes that really matter. And one is just size. And perhaps it's an obvious point, but you know, over and over again, larger facilities are at higher risk for having an outbreak and, you know, given the nature of infectious disease, that makes a lot of sense. But that has implications for disparities, as I'll show you. There's also some evidence that staffing matters that, you know, having enough staff, once you have an outbreak, having enough staff to actually implement those best practices is important and helps mitigate the effects of the outbreak and reduces the number of deaths. But that effect is still dwarfed by the effect of the virus prevalence in the surrounding community. And just to show you from one of our publications in JEGS last August, on the left, you see that there's really no relationship between staffing hours per resident day and the probability of having at least one case or some outbreak. But there is on the right hand side, there is some evidence that having more staff decreases the number of deaths you experience conditional on having that outbreak. Okay, so now I'm going to move into the disparities work we've been doing. And Rebecca and I have a forthcoming article at JAMA Network Open that focuses in on this subject. And, you know, I should say, for the sake of time, I'm not going to go through it in any detail, but there is a long history of racial and ethnic disparities in long-term care. And generally, perhaps not surprisingly, what people have found is that a higher percent of racial and ethnic minorities in a facility is correlated with a lot of indicators of poor quality and of low resource. So for example, racial and ethnic minorities are more likely to be in facilities that are larger, located in poor neighborhoods, have a higher percent of their residents on Medicaid, you know, which is the least attractive payer in this setting, have lower staffing ratios and perform worse on a variety of quality measures. Those kind of things all kind of hang together. So perhaps these results aren't surprising, but this is from our forthcoming paper. And what this graph shows is that if you look at the quintiles of the percent residents who are of white race, and so this is all facility level. So the bottom lines there show a low percent white race, as in more blacks and Hispanics and other non, and this is true if you look at blacks separately and Hispanics separately too, but just as a summary measure, we're looking at white and non-white. And so the top line is the facilities that are very white. And what you see is there's just this monotonic relationship between the racial distribution of a facility and the number of COVID-19 cases and deaths, you know, cumulatively throughout the pandemic as of, you know, December or so. And so if you look specifically at deaths, the whitest facilities have on average 1.7 deaths, the least white facilities 5.6 deaths. And this is completely unadjusted. So what we did then is try to unpack the effect and try to figure out why, right? And a lot of sort of hypotheses have been proposed. And we wanted to kind of investigate how much explanatory power each of those different hypotheses has. And so what you see in the top set of bars in this graph is just the death rates from the prior graph, right? So without any adjustment, and this is all the marginal effects compared to the whitest facilities, right? And so, you know, what you see, for example, in the top is that the facilities that are least white, you know, have almost four more deaths than the facilities that are the most white, right? So these are just sort of compared to the most white, how many more deaths does each of these facility types have. Below that, we just control for size, right? And a lot of the difference, a big chunk of the difference goes away, right? So size explains a lot. And, you know, so what does that tell us? It tells us that basically, racial and ethnic minorities tend to be in larger facilities and larger facilities have had more trouble with this pandemic. Okay. When we move down to the next group of bars, we're looking at some case mix indicators. So is it the underlying health of residents that makes a difference? No, the differences are about the same. Then we add some more nursing home characteristics. The quality measures, for example, makes no difference. And finally, we add the county prevalence of the virus. And there we see that those disparities are really diminished. So what this tells us is that we see huge racial and ethnic disparities in the number of cases and deaths from COVID-19 in nursing homes. And the two factors that explain it most are the size of facilities that people go to and the neighborhoods in which they're located in terms of the virus prevalence around that nursing home. Okay. So how should we interpret all of these findings, both generally and in terms of disparities? First of all, I think we need to focus on the fact that this pandemic represents an enormous challenge to all long-term care facilities, even the high-quality ones, right? So, I mean, I think we're just wasting time trying to figure out which nursing homes to blame and which ones deserve sort of bonuses. I think we can certainly say that the pandemic is exacerbating racial disparities in long-term care based on the numbers that I just showed you. I'll skip over the social isolation because I think Stacey handled that well. There are all these indirect effects that I think we still need to pay a lot of attention to. And then going back to policy, given the results that I showed you, I think our policies to try to address this issue have been really misguided, right? And that sort of increasing inspections in nursing homes and increasing fines for nursing homes that aren't doing well could not only be not helpful, but they could actually exacerbate disparities. So, if you think of racial and ethnic minorities going to facilities that are already under resourced and are struggling to address the pandemic in their facilities, sort of finding them for not handling the pandemic well may not help and may actually exacerbate their lack of resources. And so, I really think in the short run, we need to think about this as the crisis it is and just think about assistance and leave the sort of longer-term quality problems as a longer-term problem. I am going to skip over some of this for the sake of time, but part of what I mean by the fact that we should continue to try to assist nursing homes is that we really need to make sure that all those nursing homes still having those outbreaks have the PPE they need, have the testing they need, right, and get the vaccines they need now. That's still an important policy priority. Okay. I will end with this slide in terms of, you know, short-term and long-term suggestions for what we should be doing. I think in the short run, we really need, again, to just focus on this crisis and not try to assess blame. I think that's just a losing battle. In the long run, a lot of the problems that we're looking at go back to sort of fundamental structural problems in the way that we pay for and deliver long-term care. And so, you know, perhaps we could have avoided some of these problems if we had sort of addressed some of those underlying fundamental issues. We have a very fragmented way of paying for care and it's highly dependent on Medicaid rates, which in many states are really, really low. You know, daily rates below what we pay for a mediocre hotel. I think we also need to really rethink how we deliver care. You know, these large-scale medical model nursing homes not only did not fare well in the pandemic, but it's probably not what any of us wants and not what we look forward to in terms of the quality of life we want as we age and start to need long-term care. And I'll end on one final note. Stacey alluded to this, but the long-term care workforce is essential to the quality of care we provide in nursing homes. But basically, we pay them minimum wage, few or no benefits, and often don't have health insurance even. And then, you know, we ask them to basically work through this pandemic sometimes without appropriate protection. And so I think in the long run and in the next pandemic, we really need to find a way to better support the long-term care workforce or we're never going to solve quality of care problems in long-term care. And I will end it there. Thank you, Tamara. That was fantastic. And thank you, Stacey, as well. Let's jump into the questions. There is actually a really good question that relates to disparities. Why has the uptake of the vaccine been relatively low in long-term care compared to other settings? It appears that the fraction of vaccine distributed is particularly low in long-term care. I don't know if this is pretty important for the pandemic going forward and for disparities. Yeah, I can jump in and say, I think there were actually two, you said two different things, which is the uptake of the vaccine and the distribution of the vaccine relative to the slide that's out there. So the CDC intentionally made the process for vaccinating people in long-term care facilities different from the general population. They contracted with CVS and Walgreens to set this up for most of the nursing homes in the country, although individual states or nursing homes could opt out of that system. So part of it is just a different set of logistics about getting the vaccine to individual nursing homes. And there have been some hiccups. There have been some delays related to getting consent, which is particularly challenging in this population. And then there's just been some administrative and scheduling delays. And some states have lost patience with this and governments have added providers, other community pharmacies, for example, who are helping to speed up the process in nursing homes. I think that'll continue to get better, but I think it's just a slightly different process. In terms of uptake, we don't have good data on it yet, but anecdotally, what I hear across the country is that uptake among residents has been excellent, right? Like north of 90% often. It's uptake among staff. That's a little more concerning because that's often covering around 30 to 60%. And so that's an area where there's still concern. Yeah, I just will real quickly add to that that we've been having focus groups for echo sessions to find out where some of these concerns are still remaining. I think the education is helping tremendously. We've, you know, in my particular building, we went from 15 people to 37 people agreeing to have the vaccine with healthcare workers. So I think it is improving, but it is a constant like assessing where their minds are at, what their concerns are, and then trying to help address them in a collaborative way. Great. Thank you very much. So there's a question from Marshall about, you know, are there any countries that have gotten the COVID-19 and nursing home situation right? I'm actually thinking about Sweden and the model they adopted, which was to protect the elders, but let the virus rip through the population. Have any countries figured it out? So the best example that I've seen is actually South Korea. There's a lot of the European countries have been facing exactly what we've been facing, which is a high percentage of death in nursing homes. In South Korea, because they've handled the overall pandemic well, again, those two are very connected, right? You can't separate those policies. But because they've handled the overall pandemic well, they can implement the testing and contact tracing, first of all, and avoid the virus getting into the nursing homes in the first place. And then they've imposed some, you know, pretty draconian measures like, you know, not allowing their nursing home staff to like attend parties or, you know, they sort of monitor them in the rest of their lives and make sure they don't incur any additional risk for the facility. But I think a lot of it is about how different countries have handled the pandemic generally. That's connected to the story of community spread entering into the nursing homes and causing infection. Stacey, I wanted to ask you a question about something you mentioned, which was the fear you had for the long-term care facility of doing widespread point prevalence testing, that there would be a public backlash to the, you know, having lots of infected people. It reminds me of our recent president who did not want to test widely because it would look bad. What did you learn from your own experience in implementing, you know, public point prevalence testing about kind of public messaging and things like that? Yeah, I mean, it goes hand in hand. I think we were getting all the nursing homes in the country were getting destroyed by the media back then. And you guys all remember all the stories and everyone was just in shock and awe watching on TV. And it was a very one sided display through the media. So that we really didn't have a chance to tell our story. And I think, you know, we really had to take charge and say, no, this is going to be our story. We're going to tell them that we have a COVID response team that we are, we are aware that this is a problem and that we're going to make an example of this by doing these measures that are supported by the infectious disease people and by changing the messaging. I think it helped tremendously. I mean, we were still on the national news. I mean, it was, I mean, you know, local news, but it was still, you know, something that we were able to drive some of the messaging and I, I'm glad that we did that because I think that helped us feel a little bit better about it. Okay, there's a question in the chat about what improvements and changes could be made in long term care going forward to, you know, for the next outbreak, I guess what can, what can be done to make long term care a more vibrant place to work, a, you know, something that we want to, you know, an area of healthcare we want to go into? Absolutely. I think we need to pay our staff what they're worth. For sure, the CNAs are have the most contact with these residents, they spend the most time with these residents, and they're paid the lowest of the group. I think that's a huge way and you need an incentive to get them to come to work. The people that I work with there that have been there for years, they really love taking care of this vulnerable population. I mean, there's a lot of joy in taking care of a nursing home population, but you have to really make it worth their while. I've said from the outset of this that I'm hoping the silver lining of the, this horrible pandemic in nursing homes, I'm hoping the silver lining will be that we as a nation take a fundamental look at how we pay for and deliver long term care. There are some interesting models out there. There's a model called the greenhouse model where care is delivered in much smaller home like settings, you know, arranged around neighborhoods where you have sort of the same staff on a continuous basis interacting with the same residents. It's just not clear that can scale financially. To me, I think we're never going to fundamentally change anything until we revisit the payment system, which is a big task, but it all comes down to being willing as a nation to invest a little bit more in the long term care that we all want. So that might be the fitting end to our session, Mark. We're at the, at the time, unfortunately, but really an amazing set of talks, sort of, I feel traumatized a bit by reliving what happened in the last year, but there's sounds like some hopeful directions to go forward in the next year. I think a happy day, right? Yes. Well, I want to extend my deepest thanks to all three of the speakers. To Dr. Wang and to Tamara and to Stacey. It was outstanding and it helps us in this area that we're, as I say, emphasizing this quarter on disparities. Last week, Monica Peek spoke, and next week, Marshall Chin will be speaking. I'll give you the title of Marshall's talk next week, CARES Act Provider Relief Fund versus Fundamental Policy Reforms for COVID-19. So we will continue in this area. It's wonderful to hear that there's one country in the world that has seemed to have addressed this issue, and maybe we can learn a great deal from them. So again, deepest thanks to our three speakers today, and I look forward to seeing you as we go forward. Thank you. Thank you, everybody.